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Table of Contents
CASE REPORT
Year : 2019  |  Volume : 20  |  Issue : 4  |  Page : 175-177  

A very late and persistent thrombosis after left atrial appendage occlusion


Clinic of Cardiology, St. Marien Hospital, Hamm, Germany

Date of Submission12-Jun-2019
Date of Acceptance15-Sep-2019
Date of Web Publication14-Nov-2019

Correspondence Address:
Dr. Theodoros Sinanis
St. Marienhospital Hamm, Knappenstrase 20, 59071, Hamm
Germany
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/HEARTVIEWS.HEARTVIEWS_57_19

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   Abstract 


Atrial fibrillation (AF) is the most common cardiac arrhythmia and ischemic stroke represents the most important complication. When the oral anticoagulation cannot be taken due to bleeding problems and considerations, the percutaneous occlusion of the left atrial appendage (LAA) is a possible solution. We present a case of a very late thrombosis of the LAA-Occluder device. The thrombus was diagnosed only after the patient suffered a stroke and a regression could not be achieved, neither with apixaban nor with warfarin alone. A successful result could be observed with the combination of high dose warfarin with aspirin 100mg/day. The possible etiology of this rare complication is an incomplete endothelialization of the device.

Keywords: Atrial fibrillation, left atrial appendage occluder, thrombosis


How to cite this article:
Sinanis T. A very late and persistent thrombosis after left atrial appendage occlusion. Heart Views 2019;20:175-7

How to cite this URL:
Sinanis T. A very late and persistent thrombosis after left atrial appendage occlusion. Heart Views [serial online] 2019 [cited 2019 Dec 10];20:175-7. Available from: http://www.heartviews.org/text.asp?2019/20/4/175/271029




   Introduction Top


Cerebral ischemic stroke represents the most important fatal complication of atrial fibrillation (AF) with a stroke-related mortality rate of about 20%.[1]

In autopsy and echocardiography studies, the left atrial appendage (LAA) was shown to be the source of thrombin in >90% of patients with nonvalvular AF and a recent embolic event.[1]

Oral anticoagulation (OAC) is recommended in patients with CHA2DS2-VA2Sc score ≥1 to reduce stroke risk in these patients. However, OAC is associated with severe hemorrhagic complications.[2]

Percutaneous LAA closure has emerged as an alternative to OAC, and after the implantation of the device, a dual antiplatelet therapy (DAPT) should be considered for a minimum duration of 3 months.[2] No clear recommendation is mentioned in the current European guidelines on the duration of DAPT.[3]

The latest European guidelines classify the percutaneous LAA occlusion with IIb class of recommendation for stroke prevention in patients with AF and contraindications for long-term anticoagulant treatment[3] and point out the need for adequately powered controlled trials to inform the best use of these devices.

The presence of a thrombus on the device is a possible complication. Older age and history of stroke are known predictors of thrombus formation on the devices. An incomplete occlusion as etiology of a thrombus has also been speculated.[4],[5] Pracon et al.[6] have divided the device related thrombosis (DRT) as early (at 1.5 month), late (at 3–6 months), or very late (at 12-month follow-up). A successful treatment of the thrombus with OAC has been previously published.[4]


   Case Presentation Top


A 83-year-old female patient presented in our clinic for further evaluation after having an ischemic stroke. She has a a past history of chronic heart failure with reduced ejection fraction (25%–30%). She also has two-vessel coronary artery disease, chronic renal failure with glomerular filtration rate 44 ml/min/1.73 m2, type 2 diabetes mellitus, and arterial hypertension. A persistent AF was diagnosed 5 years ago, and an OAC with warfarin was initiated (CHA2DS2 VASc score was 7). Shortly after the initiation of OAC, she suffered a life-threatening esophagus bleeding due to varices. As the LAA was free of thrombus, an Amplatzer Cardiac Plug (ACP) Occluder 24 mm was implanted without complications. A DAPT with aspirin (100 mg/day) and clopidogrel (75 mg/day) was initiated. A transoesophageal echocardiogram (TOE) at the 2nd and 90th days showed a very good result with no signs of blood flow in the LAA. Clopidogrel was then stopped and a monotherapy with aspirin was given.

At the time of the new presentation shortly after the stroke and over 4 years after the implantation of the LAA Occluder, a new TOE was performed. In the TOE, a large thrombus (20 mm × 11 mm) on the Amplatzer Occluder device was diagnosed.

With the proof of thrombus, the treatment was switched from aspirin to apixaban (10 mg/day), and a new TOE was performed after 8 weeks. As the thrombus was consistent, a treatment with warfarin instead of apixaban was initiated (target international normalized ratio: 3.0). In the new TOE after 3 months of effective anticoagulation, there was no further improvement, and aspirin of 100 mg was added. With the combined treatment of aspirin and warfarin a regression of the thrombus was finally achieved. The patient was then left on monotherapy with warfarin, and in the last TOE after 8 weeks, a device related thrombosis (DRT) was no longer present [Figure 1].
Figure 1: Transoesophageal echocardiography shortly after the presentation with stroke and over 4 years after the implantation of the left atrial appendage occlude (a) and transoesophageal echocardiogram after initiation of a combination therapy with warfarin and aspirin (b), showing regression of the device-related thrombosis. Red arrow is the thrombosis

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From the initial presentation and up to now, the patient suffered no further ischemic or bleeding events.


   Discussion Top


In the current case report, we present a patient with a large and persistent DRT. The risk factors in the development of a thrombus are presented here (older age and history of stroke). The implanted device was an ACP Occluder device, and in the PLAATO study,[7] device thrombosis was reported (the WATCHMAN study[3] on the contrary showed no thrombosis during the follow up), but the hypothesis of a device-induced thrombosis has been questioned in registries and meta-analysis.[5]

In contrast to the previous reported cases, a single anticoagulation did not resolve the problem. We observed a persistence of the thrombus under apixaban and with high-dosed warfarin,[8] and only after the introduction of a combination therapy with aspirin and warfarin, there was an improvement.

In addition, in the TOE after the implantation (days 2 and 90 and under DAPT), there were no signs of DRT. The most possible explanation for these observations is a missing or incomplete endothelialization of the LAA occluder device, which became clinic manifest after withdrawing the DAPT.

In the vast majority of cases, the thrombus formation on the ACP Occluder is on the central screw of the device,[9] as it has happened in our case. The material used for the ACP is mostly Nitinol, except from the central screw, which is made from stainless steel.[9] The second-generation LAA occluder devices do not have the central screw, and a significant reduction on device thrombosis has been well-documented.[10]

The fact that a reduction of the thrombus was possible only after the addition of aspirin to the OAC is also a sign of the incomplete endothelialization and platelet aggregation as a cause of the thrombosis. The absence of an incomplete endothelialization has been also previously proposed as a possible cause of device thrombosis,[7] although this scenario was tested neither in the PLAATO nor in the PROTECT AF study.


   Conclusion Top


The percutaneous occlusion of LAA is an attractive solution concerning patients with AF with anticoagulation and bleeding problems. Nevertheless, the possibility of early, late, or very late DRT should be taken into account, especially in patients with known risk factors (age and history of stroke). The management of such a complication is not standardized, and a combination of warfarin and aspirin may be needed.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ, et al. Validation of clinical classification schemes for predicting stroke: Results from the national registry of atrial fibrillation. JAMA 2001;285:2864-70.  Back to cited text no. 1
    
2.
Holmes DR, Reddy VY, Turi ZG, Doshi SK, Sievert H, Buchbinder M, et al. Percutaneous closure of the left atrial appendage versus warfarin therapy for prevention of stroke in patients with atrial fibrillation: A randomised non-inferiority trial. Lancet 2009;374:534-42.   Back to cited text no. 2
    
3.
Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, et al. 2016 ESC guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Europace 2016;18:1609-78.  Back to cited text no. 3
    
4.
Fauchier L, Cinaud A, Brigadeau F, Lepillier A, Pierre B, Abbey S, et al. Device-related thrombosis after percutaneous left atrial appendage occlusion for Atrial Fibrillation. J Am Coll Cardiol 2018;71:1528-36.  Back to cited text no. 4
    
5.
Dukkipati SR, Kar S, Holmes DR, Doshi SK, Swarup V, Gibson DN, et al. Device-related thrombus after left atrial appendage closure. Circulation 2018;138:874-85.  Back to cited text no. 5
    
6.
Pracon R, Bangalore S, Dzielinska Z, Konka M, Kepka C, Kruk M, et al. Device thrombosis after percutaneous left atrial appendage occlusion is related to patient and procedural characteristics but not to duration of postimplantation dual antiplatelet therapy. Circ Cardiovasc Interv 2018;11:e005997.  Back to cited text no. 6
    
7.
Thuesen L, Pichler M, Rowland E, Ramondo A, Ruzyllo W, Budts W, et al. PLAATO (Percutaneous Left Atrial Appendage Transcatheter Occlusion) for prevention of cardioembolic stroke in non-anticoagulation eligible atrial fibrillation patients: Results from the European PLAATO study. EuroIntervention 2010;6:220-6.  Back to cited text no. 7
    
8.
Lam SC, Bertog S, Sievert H. Incomplete left atrial appendage occlusion and thrombus formation after watchman implantation treated with anticoagulation followed by further transcatheter closure with a second-generation amplatzer cardiac plug (Amulet device). Catheter Cardiovasc Interv 2015;85:321-7.  Back to cited text no. 8
    
9.
Plicht B, Konorza TF, Kahlert P, Al-Rashid F, Kaelsch H, Jánosi RA, et al. Risk factors for thrombus formation on the amplatzer cardiac plug after left atrial appendage occlusion. JACC Cardiovasc Interv 2013;6:606-13.  Back to cited text no. 9
    
10.
Tzikas A. Left atrial appendage occlusion with amplatzer cardiac plug and amplatzer amulet: A clinical trials update. J Atr Fibrillation 2017;10:1651.  Back to cited text no. 10
    


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